Provider Demographics
NPI:1063574812
Name:BROWN, GARRY G (OD)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:G
Last Name:BROWN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2623
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54903-2623
Mailing Address - Country:US
Mailing Address - Phone:920-236-4162
Mailing Address - Fax:920-236-4166
Practice Address - Street 1:719 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-2077
Practice Address - Country:US
Practice Address - Phone:920-233-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2068152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI002245140Medicare PIN
WIT61583Medicare UPIN